Monday, May 28, 2012

Epinephrine

On a scale of one – ten, rate your level of pain?”
“Fifteen,” she replied.
The nurse made a note on her clip board. “I’ll see what I can do.”
A young man clad in green scrubs entered as the nurse was leaving.
“I’m Trent McKay. I’ll be performing the surgery.”
“Nice to meet you,” Mary forced a weak smile in reply.
“Right now, I am planning to tack you on at the end of day, which should be around 9:00.” He paused, “It could be later. We’ve been running behind all day. Can you tell me how this happened?”
She gave him the short version; he didn’t need - nor she suspected - had the temperament for the long one. “I fell off the bulkhead and landed on my hip.” As soon as she said it she regretted it as the look that passed over his face told her what he was thinking. Middle aged female, fragile bones, foolish for sure; maybe feeble minded!
“Do you think you had a stroke?” This came out as more of statement than a question.
“I am quite sure I didn’t!” she emphatically replied, fixing him with the look that had unnerved her high school students years ago.
Dr. McKay’s pager went off; he looked at it, waved and left. “We’ll talk about this some more - later.”
The nurse returned with the morphine and as it began to work its way through her system, Mary closed her eyes reflected on the events leading up to this moment.

After weeks of unrelenting rain, January 13th had dawned dry and sunny. To celebrate their good fortune, weather-wise, she and Barley, a notquitetwo–year-old golden retriever set off for the beach, he with an acid green canvas lunker in his mouth and Mary with a smile on hers. Heavy rains and high winds the winter before had taken out the last 35 feet of stairs which had been repaired and replaced with a series of new stairs and switchbacks. They paused when they reached the bulkhead and realized that the final four feet of stairs that would put them on the beach was missing. Clearly, this was more of a problem for Mary than for Barley, who flew off the bulkhead, dropped the lunker, and then turned and looked at her expectantly – let’s get this show on the road! At one time Mary might well have followed suit but a torn anterior cruciate ligament and ragged meniscus that led to a total knee replacement a few months previously had made her more cautious. As a consequence, a more circumspect approach was called for. She knelt at the edge of the log bulkhead with her back to the water; intent on down climbing, she gingerly extended her left leg, seeking a foothold on the logs below. She shifted her weight over her left leg, but when the foothold failed her, she slipped backward, landing with all her weight on her left hip. The sand at the moment of contact felt more like cement than sugar. A flash of light behind her eyes accompanied by sharp pain and a momentary loss of consciousness suggested the possibility of a serious injury. Her first thought was a concussion but given the point of impact that seemed unlikely.

Regrettably, this beach-induced insight that something serious had happened was fleeting. Once she got back in the house, she felt euphoric and downright smug about her achievement, so that she carried on as if nothing had happened. She got out the broom, swept the floor and built a fire to take off the chill. Even though the day was sunny, it was still January with high temperatures cresting in the 40’s. Besides, she felt clammy. When she discovered that she was out of Advil she called her neighbor Pam. There might be some upstairs but at the moment tackling yet another flight of stairs didn’t appeal to her. Pam arrived, located the Advil, helped onto the sofa and promised to check back with her in an hour or so.

“I’m sure I’ll be fine. Ibuprofen is the wonder drug!” she assured her. For the moment, ‘denial’ was clearly in the ascendancy, though, in a matter of hours, it would crash to earth.

Around 11:00 P.M. a tired looking Dr. McKay returned to her room “We can operate now,” he glanced up at her,”but I’d rather wait until tomorrow.”

“That’s fine with me,” she replied, now that the morphine was coursing through her system, there didn’t seem to be any rush. By the time her hospital stay was over she would arrive at a heightened appreciation of pain. Medication might dull the pain but didn’t obliterate it; she realized, however, that she had the power to control it to a certain extent; to move it off center stage to the wings, as if it were a vase of cabbage roses blocking the view of her dining companion. It remained there in her peripheral vision but no longer front and center.

Dr. McKay continued, “Let me give you an idea of what you can expect following the surgery.” Nothing that had happened to her so far was as scary as what followed.
“Expect to spend four to six days in the hospital following the surgery and then another six or seven days at a rehab center.”
“Real-ly?” she replied, her voice dropping on the second syllable.
“Of course, if things go well, those times might shorten up a bit. But that’s the schedule I prefer and the one you should plan on.” He rose, smiled tiredly, “I’ll check in with you tomorrow.”We’ll see about that! She congratulated herself on keeping her mouth shut. Going forward there would be ample time to straighten him out. She smiled to herself, and then lay back against the pillows of her hospital bed.

In her living room, she had adjusted the sofa pillow as she took in the view of the Olympic Mountains and the Sound that never failed to soothe her; today was no exception. The wind had picked up so the water was rougher, but still it looked much the same as it had an hour ago. How long ago was it that I went to the beach? She had no concept of time anymore. More than an hour, she concluded. Maybe two?

She remembered that she and Janey were meeting at Casa Mia for dinner tonight and then going to the library to hear Garth Stein talk about his book they both had loved, The Art of Racing in the Rain. She and Janey were ‘dog people’ and had laughed and cried in the same places in the book.
She was annoyed that she hadn’t asked Pam to bring a phone into the living room. As it was, she would have to get herself to the kitchen in order to make a call. She was beginning to feel antsy anyway; she couldn’t stay on the sofa all day! She tried to sit up and fell back against the cushions. Ow! A violent pain took her breath away and left her feeling faint. It was hard to sit up without bending at the waist but she would have to find a way. After a few more painful false starts, she managed to get upright by planting her right foot firmly on the floor and pushing off with her right hand. A graceless gymnastic vault – but it worked. She made it to the phone and called Janey.

“Oh hi Mary, what time should we meet tonight?”
Mary paused. “Um - I hate to do this but I don’t think I can make it. I had a little tumble on the beach this morning . . .”
“Oh dear,” Janey broke in, “did you hurt yourself?”
“That remains to be seen. I slipped off the bulkhead and landed with all my weight on my left hip.” She paused, and then added. “It feels like a bad sprain.”
Janey chuckled. “Mary, you know you can’t sprain your fanny!”
“I know; it feels like it though.”
“You need to go to the hospital.” Janey said matter-of-factly. Mary was beginning to agree with her but by now was pretty sure she couldn’t drive herself. Janey interrupted her thoughts.
“You don’t sound like yourself. I’m coming out and can drive you there. ”

After a hard landing, she didn’t feel much like herself. She began to straighten herself out of the crumpled position she had landed in. In a rush, everything that she needed to do occurred to her. For starters, she couldn’t continue to lie on the beach much longer. The tide was coming in fast and she had to get a move on. She wiggled her fingers and toes; relieved that everything seemed to be in working order, maybe I just have a bad bruise - a hematoma - her doctor daughter would have called it. She took a deep breath, exhaled as she rolled over, and then pushed herself up on all fours. About that time, Barley pressed the lunker, wet and coated with sand into her face.

Unlike Lassie, Barley didn’t have rescue on his mind. Retrieving was in his DNA and she had a necessary role to play. From the crouched position she was able to lob the lunker a short distance into the water distracting Barley long enough to crawl to the bulkhead and pull herself up. She leaned against it until the dizziness went away. In between lunker launchings, she calculated her next move which, all things considered, was the most challenging. She had to get back up on the bulkhead in order to access the stairs to get back to the house. Climbing back up the slick logs was obviously not an option.

On the other side of the boathouse there was a jumble of rocks and logs that had ridden in on a high tide and stayed there. They formed a rough ladder that she managed to scramble up. With that task behind her, she steeled herself for the hardest part - walking along the eight inch concrete wall in front of the boathouse. Several seasons worth of high tides had long since washed the sand away between the concrete wall and the building, making the crossing treacherous, even in the best of circumstances. She paused and let Barley go ahead of her – she was feeling unstable enough and didn’t need a wet impatient dog pushing her from behind.

She braced herself with her hands against the weathered double doors and cautiously side stepped the distance that was no more than fifteen feet but seemed like half a mile. She made it and buoyed by her successful crossing, she began the ascent of the final 85 feet with marked dispatch. She thought it would be harder than it actually was and before she knew it she ‘summitted’. Along the way, she employed whatever technique seemed to work - in some places, she could pull herself along, hand over hand using the railing. Where the stairs were the steepest, she crawled on all fours, crab-like. It wasn’t until afterwards when people would ask her how she did it that appreciated the difficulty.

“I didn’t have any options – and of course, I was in shock,” became her stock reply.

Later, after she was long gone from the hospital, she learned that medically speaking ‘shock’ was not the correct term. It was her hypothalamus that saved her by signaling the pituitary, which signaled the adrenals to send out the advance party in the ‘fight or flight’ reaction, that motley crew of hormones that came into their own at a more primitive time and fortunately can still be called into service to suppress pain and boost energy – at least temporarily.

Mary decided to make tea before Janey arrived. The electric kettle was in the kitchen, one short step up from where she now stood and she found she couldn’t manage it. In hindsight, it is quite likely that the prospect of facing the rest of the day without tea is what finally brought her to her senses.

“I don’t think I can get into your car Janey,” Mary told her, as she hung over the barstool, to take the weight off her hips. Comfortable positions were becoming scarce.
“I’ll call 911. What do you think?” Mary didn’t say anything while Janey picked up the phone and placed the call.
Then Mary said, “I need to call Kate and leave a message that I won’t be home this afternoon.” Kate had promised a chat that afternoon when she got home from work. Kate was a third year anesthesiology resident and the weekly phone call that Mary unapologetically lived for required considerable advance planning.
She punched in the number and spoke to their answering machine, advising Kate and her husband that she had ‘taken a spill’ at the beach that day and was popping over to the hospital to have it checked out.
“Don’t worry; I’m sure it’s nothing serious. I’ll call when I get back home this afternoon and let you know what I find out.” Before she could sign off, she heard the wail of the emergency vehicle careening around the corner. Most likely their answering machine heard it as well.
“Oh shit!” she said and hung up the phone.

Janey followed the emergency vehicle to the hospital and sat with her in the ER. There was a shortage of gurneys in the emergency room but no shortage of emergencies, so Mary was offered a wheel chair instead. She knew she couldn’t sit in it but with her legs stretched out in front of her and her back where her bottom ordinarily would be, she was reasonably comfortable.

I have been moving around like a crab all day, she thought to herself as she rolled into the cubicle marked ‘admissions’ where the woman asked for her medical insurance card. After that she crab-walked her way to an examining room. X-rays followed. During the interval, she thought about calling her daughter but was told that cell phones didn’t work in that part of the hospital. Just as well, she thought as she still didn’t have much to report.

The young ER doctor who introduced himself to her in the examination room returned - ashen after seeing the x-rays - and informed her that the ball of her femur had broken off, and was floating around in her hip. She imagined a golf ball, bouncing back and forth between her femur and her pelvis. She winced at the image.

“You’re probably experiencing significant pain,” he volunteered, nodding as he did so.

“Yes I am.” She spoke deliberately but she tried not to sound cranky. After all, none of this was his fault. “Please call my daughter and explain this to her. You speak the same language.” She handed him her cell phone. By now, even if reception was possible, she didn’t want to make the call. He took the phone and left the room.

She left the examining room herself shortly after that and was taken to the sixth floor of the hospital, the orthopedic wing she remembered from last year’s knee replacement. Sometime, after the doctor’s first visit and the nurse’s second that introduced morphine to her system, Kate called.

“I’m flying out tomorrow morning and should be there by early afternoon.”
“Oh honey, you don’t need to come. I’ll be fine.”
“I’m sure you will be mom, but I am coming anyway. Where’s dad?” she added.
“He flew to Texas a few days ago, in order to go to Padre Island and Port Aransas.”
“What’s the attraction?” Kate asked.
“Spoonbills and whooping cranes. They winter there, I guess. By now, he ought to be in Belize.” When Mary and Barley returned from the beach that morning, there was a message from Fred calling from the Dallas – Fort Worth airport, en route to Belize.
“Does he know you are in the hospital?”
“Gosh no – and I really don’t want him to!” Mary paused; actually, she didn’t know if there was a way to call him. Mary and Fred were appalling casual about that kind of information, much to their friends’ and family’s frustration.
“I really don’t want dad to know about this. Promise me you won’t tell him.” It was Kate’s turn to pause.
“Okay,” she finally said. “I won’t.” They chatted a bit longer and then rung off with “see you tomorrow.”

As it turned out, she wasn’t taken into surgery until close to seven the next evening so Kate was able to be with her in the pre-op room. “I’m sorry you felt had to come," Mary said as she held her daughter’s slender hand, “but I am glad you’re here.” Mary looked over; Kate’s eyes were brimming with tears.
“Oh honey, don’t worry about mom. You know how tough I am. Everything is going to be fine.” Even while she said it she realized that her daughter’s perspective would be altered by their relationship as well as her work. Kate bit her lip and nodded but the tears still spilled down her cheeks. She wiped them away with the back of her hand, sniffed and then laughed at herself.
The nurse arrived to take Mary into the surgery room. Kate kissed her cheek and followed the nurse’s directions to the waiting room.

The procedure went smoothly and by the time Mary was brought back to her room Kate was there waiting for her with a smile on her face.
“How do you feel?” she asked her mother.
“Great. I feel great!”Mary waved her hand to emphasize her point.
Kate confirmed that they had given her mother a regional block in addition to the general anesthetic. “You should be pretty comfortable for the next twelve hours, maybe longer if you’re lucky.”
“I don’t expect my luck to run out anytime soon.”
“Dad called a little while ago from the airport. He should be here in half an hour or so.”
Mary’s eyes took on that hard look that signaled her displeasure.
“You promised you wouldn’t call him!”
“I didn’t. Somebody else did.” Kate looked away and then back at her mother. "I told them to."
“He’s going to be mad that I ruined his dive trip.”
Kate rolled her eyes. “Not as mad as he’d be if he hadn’t been told!”

Three days later she was discharged from the hospital, not to a rehab facility but to home. Fred and Kate had put an extra mattress on the Murphy bed in the computer room so that she could get in and out of bed without lowering her hip below her knees. Kate worked up a spread sheet for ‘Mary Care’ assigning friends to drive her to physical therapy and doctor appointments until she could drive herself.

In the days and weeks that followed, Mary retold the story many times, shamelessly basking in the wonderment of her audience. “Necessity fueled by adrenalin makes heroes of us all!” she often concluded, pleased with that particular turn of phrase. Kate informed her that ‘epinephrine’ was another word for adrenalin. Epinephrine – epinephrine. She liked the sound of it, the way it rolled off her tongue.

Over time, she came to realize something about the heroes of the story as well as the extent of her indebtedness. Of course there were the medical heroes –not just the surgeon and the folks at the hospital, but the surgical pioneers who had figured out how to do this procedure in the first place. If this had happened thirty years ago, I’d never walk again! she reminded herself.

Most of her heroes, however, were closer to home; they were the friends and family members who looked out for her; who ignored her when she told them to stay away.

They were her girlfriends who met Kate in the surgery waiting room, took her to dinner then stayed with her, distracting her with laughter and stories until Dr. McKay arrived to tell her that her mother was out of surgery. Then the friends went home; they hadn’t come to see Mary - they had come to be with Kate.

“How did they know I was even in the hospital?” Mary asked her when Kate told her about it.
“Oh mom, this is Olympia. Everybody knows!”

Maureen and Don were special heroes; they sat with Mary in her room, and fixed her tea or found saltines for her if she asked for them. But mainly, they just sat quietly, bringing serenity in with them, like a cashmere throw over her shoulders.

Fred was a hero as well, for when she apologized for ruining his dive trip, he smiled and shrugged. “I didn’t miss much. The storm had stirred up the water so the visibility would have been lousy.”

Epinephrine may have made Mary look like a hero, at least momentarily; but it was the unfailing loyalty of her noble family and friends that made her feel like one.

1 comment:

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